BACKGROUND:Photon-counting detector CT (PCD-CT) is a technology that directly counts individual photons and their energy, compared to conventional energy-integrating detector CT (EID-CT) which measures the total deposited X-ray energy without distinguishing photon energies. PCD-CT promises to provide higher quality images at equal or reduced radiation doses. We aimed to compare the objective and subjective image quality of PCD-CT to EID-CT for low-dose chest CT. METHODS:Asbestos-exposed participants from the Western Australian Asbestos Review Program underwent paired EID-CT (2023-2024) and PCD-CT (2024-2025) at a reduced radiation dose. Three independent chest radiologists rated relative image quality on a 5-point Likert scale, with higher scores indicating better quality on the right-hand image. Quantitative image noise was measured in the descending thoracic aorta. Interobserver agreement was assessed using κ statistics, intraclass correlation coefficients (ICC), and near-agreement (±1 category). RESULTS:Fifty subjects (median age 77 IQR 10.25 years; 40 men) were included. Across 150 ratings, 88% fell in categories 'somewhat higher' (4) or 'much higher' (5), favouring PCD-CT. The pooled mean score was 4.2. Individual reader mean scores ranged from 3.6 to 4.7. Interobserver agreement was modest by exact κ statistics, but near-agreement (±1 category) was high (80%-98%) and intraclass correlation coefficients demonstrated strong reader consistency. Quantitative analysis showed similar image quality despite approximately 40% reduced radiation dose for PCD-CT. CONCLUSIONS:PCD-CT provides superior subjective image quality to EID-CT for low-dose chest CT, at a substantially reduced radiation dose. TRIAL REGISTRATION:Clinical trial number: ACTRN12621001627842; https://www.anzctr.org.au/.

BACKGROUND:Mining workers are exposed to a range of respiratory hazards, including respirable dust. While exposure to respirable crystalline silica in the mining industry has been found to be common, less is known about trends in measured levels of exposure to respirable dust overall. METHODS:This study analyzed 109,442 personal respirable dust measurements collected from Western Australian mines between 1986 and 2014. Data were sourced from an industry-wide monitoring database and modeled using mixed-effects regression, adjusting for sampling characteristics (year of measurement, duration, reason), mine type, and job title. Differences in trends over time between mine types were also examined. RESULTS:Overall geometric mean respirable dust concentrations declined from 0.393 mg/m³ in 1986-1990 to 0.181 mg/m³ in 2011-2014, representing an average annual decrease of 3.51% (95% confidence interval -3.63% to -3.39%). Modeled exposure levels varied by mine type, with the highest levels observed in iron ore mines (GM 0.489 mg/m3 in 1986 through to 0.197 mg/m3 in 2014) and exploration (GM 0.665 mg/m3 in 1994 through to 0.172 mg/m3 in 2014). Temporal trends varied by mine type, with a steeper decline in exposure levels seen in exploration activities in particular. CONCLUSIONS:Exposure to respirable dust in Western Australian mines has decreased substantially over the past three decades, although higher levels persist in some jobs and activities. While this suggests that existing controls have been broadly effective, the presence of these higher exposures indicates that further measures may be required.

Uptake of lung cancer screening (LCS) in high-risk populations remains suboptimal internationally. Primary care practitioners play a critical role in identifying eligible patients and initiating referrals for LCS. Targeted implementation strategies are needed to address health care barriers to the uptake of LCS such as limited awareness, eligibility assessment, low engagement, and poor health system preparedness. Implementation trials are needed to determine optimal decision-making and participant knowledge gains to ultimately increase screening uptake. The Ready to Screen trial is a cluster randomized controlled implementation trial to compare participants’ intention to screen for lung cancer in the Australian National Lung Cancer Screening Program (hereafter ‘the Program’) between bundled (intervention: core + link to multilingual trial website + SMS and email reminders, clinical decision support prompts for general practitioners) and core (control (core): initial letter mail out with LCS brochure only) implementation strategies. Twenty-eight general practices recruited across Australia will be randomly allocated (1:1 ratio) to either control or intervention. Practices will generate eligible patient lists using medical records to issue participation invitations. Eligible patients are aged 50–70 years and currently smoke or have quit within the past 10 years or have an unknown quit date. The primary outcome is participant intention to screen from self-report survey at patient recruitment. Secondary outcomes will be evaluated using the RE-AIM framework—examining Reach, Effectiveness (including cost-effectiveness), Adoption, Implementation and Maintenance. The PRISM framework will guide assessment of multi-level contextual factors hypothesized to influence these outcomes. Data collection will include trial recruitment and practice records, participant and provider self-report surveys, and semi-structured interviews. This trial will generate timely evidence about the effectiveness and cost-effectiveness of the bundled implementation strategy to support delivery of the Program within primary care practices. Findings will provide insights into contextual factors shaping implementation success and inform the future scaling and sustainability of LCS in Australia and internationally. ACTRN12625000045415 registered on 20/01/2025.

INTRODUCTION:Lung cancer is the leading cause of cancer mortality in Australia. In July 2025, the Australian Government launched the National Lung Cancer Screening Program (the Program). The Program has been designed in accordance with the Medical Services Advisory Committee's recommendations. This article summarises the program guidelines, outlining Program parameters and delivery requirements. The screening and assessment pathway defines the Program structure. The purpose of the guidelines is to ensure safe, effective and high-quality Program delivery, detailing key steps for clinical practice and information for participating healthcare providers. MAIN RECOMMENDATIONS:The guidelines provide recommendations for the delivery of targeted low-dose CT screening for lung cancer in the Australian context. Program eligibility is assessed using risk-based eligibility criteria recommended by the Medical Services Advisory Committee, targeting people between 50 and 70 years of age with a history of tobacco cigarette smoking. Smoking cessation supports are to be offered to all potential participants by healthcare providers across the lung cancer screening and assessment pathway. Low-dose CT scan assessment and reporting follow the National Lung Cancer Screening Program's nodule management protocol. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE:This guideline provides recommendations for the delivery of targeted low-dose CT screening for lung cancer in the Australian context. Content includes: guidance on assessing Program eligibility; enrolling eligible participants in the National Cancer Screening Register; completing and fulfilling low-dose CT scan requests; assessing and reporting low-dose CT scan results; managing scan outcomes and actionable additional findings; and communicating scan results. The full guideline is available at https://www.health.gov.au/resources/publications/nlcsp-guidelines.

OBJECTIVES:Asbestos exposure raises the lung cancer risk and has supra-additive synergy alongside tobacco exposure. Lung cancer screening (LCS) is effective when high-risk populations are targeted. This study examined the utility of various LCS eligibility and risk prediction models in an asbestos-exposed population. METHODS:The Western Australia Asbestos Review Program (ARP) consists of individuals with known exposure to asbestos. All participants underwent annual review with low-dose CT screening. The performance of the Prostate, Lung, Colorectal and Ovarian (PLCO)m2012, PLCOm2014 and PLCOocc models, Liverpool Lung Project V.2 (LLPv2) and Bach models, together with the United States Preventive Services Task Force (USPSTF)2021 and Australian LCS eligibility criteria were validated on the ARP. RESULTS:The cohort consisted of 2126 participants of which 85.4% were male with a median (IQR) age of 70 (63-75) years old. Former smokers comprised 55.1% (n=1172) and never smokers 36.2% (n=769) of the cohort. Median smoking and cessation duration were 24 years (IQR: 13-72) and 32 years (IQR: 22-41), respectively. Lung cancer was diagnosed in 51 (2.4%) participants.When applying the risk models to the ARP cohort, the area under the curve for all models was modest, ranging from 0.602 to 0.675. All models underestimated risk in this cohort during calibration assessment, with the exception of the LLP V.2, which overestimated risk. CONCLUSIONS:In an asbestos exposed population, current LCS eligibility criteria and risk models mostly underestimate the risk of lung cancer, reflecting the need for improved risk prediction models that adequately account for asbestos exposure.

OBJECTIVE:This review will examine how reduced-dose computed tomography (CT; ≤1.5mSv), compared with conventional-dose CT (>1.5mSv), performs in detecting parenchymal lung abnormalities in humans and phantoms undergoing chest CT imaging. INTRODUCTION:Deliberate exposure to ionizing radiation during medical investigations, such as chest CT, should be as low as reasonably practicable to reduce the risk of inducing cancer. Certain populations are at particular risk, such as those undergoing lung cancer screening and workers exposed to dust, and require multiple scans over time with high baseline risk. It is unclear whether reduced-dose CT scans provide sufficient image quality to accurately identify relevant lung abnormalities. ELIGIBILITY CRITERIA:Crossover studies including a non-contrast, reduced-dose CT scan (≤1.5mSv or 107mGy·cm) compared to conventional-dose CT, and reporting on at least 1 parenchymal lung abnormality will be considered. Comparison to only chest x-ray will be excluded. METHODS:The proposed systematic review will be conducted in accordance with Cochrane methodology for systematic reviews of diagnostic test accuracy, incorporating additional quantitative performance measures where applicable, and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Diagnostic Test Accuracy (PRISMA-DTA). MEDLINE (Ovid), Embase (Ovid), and Scopus will be searched for articles published from January 1, 2014, to March 31, 2026. Prospective within-subject crossover studies will be considered, and systematic reviews will be screened for eligible primary studies. Risk of bias will be evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool, with adaptation as required. Data on study and participant characteristics, CT acquisition, and performance outcomes (including diagnostic accuracy, agreement, and image quality metrics) will be extracted. Data will be synthesized using meta-analysis, where feasible, or narratively. REVIEW REGISTRATION:PROSPERO CRD42025631825.

OBJECTIVES:The impact of early-life exposure to asbestos on disease risk remains uncertain. Childhood exposure to blue asbestos at Wittenoom has previously been linked to the development of malignant mesothelioma and various cancers in adulthood, as well as to a greater risk of all-cause mortality compared with the general population. This study aims to provide an update on mortality and cancer incidence rates after this exposure. METHODS:The cohort of all those who lived in the asbestos mining town of Wittenoom as children (less than 15 years of age; 1279 males and 1185 females) was linked to state and national cancer and death registries. We calculated standardized incidence ratios (SIRs) for a range of cancers, and standardized mortality ratios (SMRs) for all-cause and cause-specific mortality for the cohort compared with the general Western Australian population. RESULTS:Compared with the Western Australian population, males from the cohort had an increased risk of all cancers and mesothelioma, as well as melanoma and cancers of the lip and mouth, liver, and brain. Females had a significantly elevated risk of all cancers, mesothelioma, and cancers of the ovary and brain. Higher rates of mesothelioma were observed among those with a longer duration of exposure and higher cumulative exposure, consistent with a known exposure-response relationship. Former Wittenoom children also had a greater risk of all-cause mortality and mortality from cancer, mesothelioma, and ill-defined symptoms. CONCLUSIONS:This update confirms earlier studies and shows that exposure to asbestos in childhood is associated with several cancer and mortality outcomes in adulthood.

Mesothelioma is a lethal cancer caused by exposure to asbestos, which arises predominantly in the pleural lining of the thoracic cavity or, less commonly, in the peritoneum, pericardium or tunica vaginalis. The incidence of mesothelioma increased globally during the late twentieth century, correlating with the use of asbestos, and it continues to rise in some regions. Asbestos tumorigenesis involves fibre persistence that leads to DNA damage mediated by chronic inflammation. The genomic landscape of mesothelioma is predominantly characterized by tumour suppressor alterations, most frequently occurring in BAP1, CDKN2A, CDKN2B, MTAP, NF2 and TP53. Patients with mesothelioma commonly present with fatigue, dyspnoea and/or cough caused by pleural effusion, pain and reduced appetite with weight loss. Imaging, cytology, histology and immunohistochemistry are used in diagnosis and support tumour staging. Genetic tests are relevant to reveal disease predispositions. Mesotheliomas are classified on the basis of histology into three distinct subtypes: epithelioid (the most common subtype with the best prognosis), biphasic and sarcomatoid (worst prognosis). Chemotherapy has been the standard of care for the past two decades but immune checkpoint inhibition targeting PD1 and CTLA4 is now considered to be the first-line treatment, showing improvement compared with chemotherapy. Few randomized trials have investigated the role of surgery and radiotherapy and none has found a clear benefit over systemic therapies. Mesothelioma is associated with considerable negative effects on quality of life in physical and emotional domains and also substantially affects patients' families and caregivers.

Background: Lung cancer has the highest burden of cancer in Australia and delays in healthcare can significantly worsen outcomes and cause psychological harm. Australian Optimal Care guidelines recommend a 14-day interval between primary care referral and an appointment with a specialist, however, many healthcare providers are not currently meeting this target. The aim of this pilot study was to assess the patient experience during the interval between referral from primary care to being seen in tertiary care. Methods: We recruited patients with suspected lung cancer referred to a tertiary respiratory clinic. A questionnaire was conducted including Likert-style questions to understand patient perspectives of timeliness, coordination, and communication regarding the early stages of lung cancer care. Additional open-ended questions were included to expand the understanding of patients’ perspectives. Results: The questionnaire was completed by 37 of 52 eligible participants (71%), the median age of participants was 69 years old (IQR 15.5-33.5) and the most common diagnosis was lung adenocarcinoma. Overall, patients reported a positive perception of timeliness of care, despite wait time of median 25 (IQR 15.5-33.5) days. Just one participant stated they were aware of a timeliness clinical guideline. The most common stressors reported by patients were ‘fear of the unknown’ and ‘waiting.’ Conclusions: There appears a paradox in perception of expected wait time within the healthcare system and reported concerns by individuals with suspected lung cancer. Awareness of timeliness guidelines is poor. There is scope for interventions such as improved information resources and access to earlier telehealth appointments to impact on patient reported satisfaction.

Mesothelioma is a lethal cancer caused by exposure to asbestos, which arises predominantly in the pleural lining of the thoracic cavity or, less commonly, in the peritoneum, pericardium or tunica vaginalis. The incidence of mesothelioma increased globally during the late twentieth century, correlating with the use of asbestos, and it continues to rise in some regions. Asbestos tumorigenesis involves fibre persistence that leads to DNA damage mediated by chronic inflammation. The genomic landscape of mesothelioma is predominantly characterized by tumour suppressor alterations, most frequently occurring in BAP1, CDKN2A, CDKN2B, MTAP, NF2 and TP53. Patients with mesothelioma commonly present with fatigue, dyspnoea and/or cough caused by pleural effusion, pain and reduced appetite with weight loss. Imaging, cytology, histology and immunohistochemistry are used in diagnosis and support tumour staging. Genetic tests are relevant to reveal disease predispositions. Mesotheliomas are classified on the basis of histology into three distinct subtypes: epithelioid (the most common subtype with the best prognosis), biphasic and sarcomatoid (worst prognosis). Chemotherapy has been the standard of care for the past two decades but immune checkpoint inhibition targeting PD1 and CTLA4 is now considered to be the first-line treatment, showing improvement compared with chemotherapy. Few randomized trials have investigated the role of surgery and radiotherapy and none has found a clear benefit over systemic therapies. Mesothelioma is associated with considerable negative effects on quality of life in physical and emotional domains and also substantially affects patients’ families and caregivers. Pleural mesothelioma is a cancer that arises in the lining of the lung and is caused by exposure to asbestos. In this Primer, Fennell et al. discuss the epidemiology, pathophysiology, diagnosis and management of this disease, as well as patient quality of life and new research developments.

INTRODUCTION:Lung cancer risk increases with time, and participants who are initially ineligible for lung cancer screening (LCS) could become eligible later. The aim of this study was to determine the proportion of people (initially ineligible) who may become eligible in a risk model-based LCS programme and the impact smoking cessation could have on this cohort. METHODS:All potential participants for the International Lung Screening Trial aged 55-80 years, ineligible for Low-dose CT screening at baseline (PLCOm2012<1.5% 6-year risk), were included. Assuming annual increments of change in age, smoking duration and quit time, and under the assumption of other risk variables being constant, projections of risk were made using the PLCOm2012 model from evaluation to the upper age limit of 80 years. RESULTS:4451 subjects with a median age of 61 (IQR: 57-66) years were included. Assuming no change in smoking status post evaluation, 2239 participants (50.3%) became eligible (PLCOm2012≥1.51%) by age 80, with 26.9% and 38.7% of the cohort reaching eligibility by age 70 and 75 years, respectively. Among participants with a baseline risk≥0.6%, 1518 (34.1%) reached eligibility within 10 years of initial evaluation. Smoking cessation after first evaluation can reduce the proportion of individuals who may become eligible for LCS by age 70 from 68.7% to 24.9%. CONCLUSIONS:Future risk projection of eligibility could provide a time window for reassessment of risk on an individual level. It is important to provide smoking cessation services to individuals who are ineligible for LCS at the initial programme contact.

The increasing adoption of lung cancer screening programs and advancements in imaging technologies has significantly increased the detection of pulmonary nodules, both incidentally and through screening. This document provides a comprehensive guide for clinicians to address the complexities of managing indeterminate pulmonary nodules (IPNs), emphasising person-centred and multidisciplinary care. IPNs are categorised based on size and morphology, with specific guidelines for malignancy risk stratification, diagnostic evaluation, and follow-up. Dedicated lung nodule evaluation teams (LNETs) and nodule multidisciplinary meetings (MDMs) play a critical role in ensuring guideline adherence, streamlining the diagnostic pathway, reducing unnecessary investigations, and improving outcomes. Structured IPN programs have demonstrated benefits in early lung cancer detection, improved detection of early-stage lung cancer, and reduced delays to treatment initiation. Effective management strategies include use of standardised reporting templates, utilising validated risk models such as the PanCan malignancy risk model and agreed protocols for follow up of IPNs. This document highlights the importance of accessing prior imaging to assess for growth and accounting for technical differences between computed tomography (CT) scans. Any nodule considered to be growing requires discussion at a nodule MDM with decision to act for tissue biopsy as appropriate. A nodule MDM will assist in optimising the safest and most efficient biopsy techniques based on nodule characteristics and risk profile. By integrating multidisciplinary expertise and adhering to evidence-based protocols, services can improve the timely diagnosis and management of IPNs, minimise over-investigation, reduce chance of overdiagnosis and ultimately enhance patient outcomes and lung cancer survival.

Mesothelioma is a lethal cancer caused by exposure to asbestos, which arises predominantly in the pleural lining of the thoracic cavity or, less commonly, in the peritoneum, pericardium or tunica vaginalis. The incidence of mesothelioma increased globally during the late twentieth century, correlating with the use of asbestos, and it continues to rise in some regions. Asbestos tumorigenesis involves fibre persistence that leads to DNA damage mediated by chronic inflammation. The genomic landscape of mesothelioma is predominantly characterized by tumour suppressor alterations, most frequently occurring in BAP1, CDKN2A, CDKN2B, MTAP, NF2 and TP53. Patients with mesothelioma commonly present with fatigue, dyspnoea and/or cough caused by pleural effusion, pain and reduced appetite with weight loss. Imaging, cytology, histology and immunohistochemistry are used in diagnosis and support tumour staging. Genetic tests are relevant to reveal disease predispositions. Mesotheliomas are classified on the basis of histology into three distinct subtypes: epithelioid (the most common subtype with the best prognosis), biphasic and sarcomatoid (worst prognosis). Chemotherapy has been the standard of care for the past two decades but immune checkpoint inhibition targeting PD1 and CTLA4 is now considered to be the first-line treatment, showing improvement compared with chemotherapy. Few randomized trials have investigated the role of surgery and radiotherapy and none has found a clear benefit over systemic therapies. Mesothelioma is associated with considerable negative effects on quality of life in physical and emotional domains and also substantially affects patients’ families and caregivers. Pleural mesothelioma is a cancer that arises in the lining of the lung and is caused by exposure to asbestos. In this Primer, Fennell et al. discuss the epidemiology, pathophysiology, diagnosis and management of this disease, as well as patient quality of life and new research developments.